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ABSTRACT Nurses have a professional duty to provide care for all patients regardless of race, ethnicity, religion, gender, disability, sexual orientation, or gender identity. As Christian nurses, we are called by our profession and faith to welcome and care for those who are stigmatized by others. This article defines LGBT (Lesbian, Gay, Bisexual, Transgender), offers reasons why LGBT persons are at risk for healthcare disparities, discusses referral of LGBT persons to healthcare resources, and states ways to be more welcoming for LGBT persons in a faith setting.

Surveys reveal that most gays align themselves with Christianity and one-third attend church regularly. The average age a person first experiences same-sex attraction is 13; the average age they “come out” is 15. Learn about LGBT, why gay persons are at risk for healthcare disparities, how to refer to health resources, and ways to be more welcoming for LGBT persons in a faith setting.

Sarah Sanders, BSN, RN, CCRN, is a Faith Community Nurse and member of First Congregational United Church of Christ in St. Louis, MO; a critical care nurse at St. Louis VA Medical Center; and a hospice volunteer. Sarah offers courses in culturally competent care for LGBT persons to healthcare professionals.

Conflicts of Interest and Source of Funding: Sarah Sanders has received honoraria for teaching classes for faith community nurses on providing culturally competent care for LGBT persons.

No honoraria or other source of funding was received for this article.

Thank you for deciding to read about this important topic. Maybe, like me, you feel God is calling you to be a better witness of his love to gay friends, coworkers, or family members. Maybe gay members of your faith community need assistance from a nurse, but you do not know how to help. Maybe your city is still reeling from the tragic suicide of a gay youth who gave up hope of finding love and acceptance. Unfortunately, many communities across the United States have experienced just such a tragedy. The suicide deaths of teens Asher Brown, Billy Lucas, Justin Aaberg, Seth Walsh, and others remind us that Christians have work to do in sharing God's unconditional love with those who feel rejected.

The average age a person first experiences same-sex attraction is 13; the average age they “come out” is 15 (Marin, 2009, p. 23). How can a nurse within a faith community be a healing force? What can we do to ensure that the adults and youth in our churches know they are fearfully and wonderfully made (Psalm 139:14), that there are no exceptions to God's love? How might we communicate that even if teens are bullied at school and cast out by family, they can find support and love from us and from God?

MOVING BEYOND STIGMA

This is not an article about the origins (i.e., nature vs. nurture) or morality (rightness or wrongness) of homosexuality. This article is about healthcare and extending God's love. Whatever you believe about homosexuality personally, Christians can agree that Jesus calls us to a ministry of love and healing (Luke 9:1–2). He called us to be living sanctuaries for those rejected by worldly society (Matthew 5:13–16). When we care for the most vulnerable of his people, we are caring for him (Matthew 25:34–46).

Nurses have a professional duty to provide culturally competent care for all patients regardless of race, ethnicity, religion, gender, disability, sexual orientation, or gender identity. Provision 1 of the American Nurses Association (ANA) Code of Ethics states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (ANA, 2001, p. 3). Interpretive statement 8.2 adds, “In providing care, the nurse should avoid imposition of the nurse's own cultural values upon others. The nurse should ... use approaches to care that reflect awareness and sensitivity [to cultural values]” (ANA, 2001, p. 13).

We are called by our faith and our profession to welcome those who feel isolated, ostracized, and stigmatized. All nurses and especially faith community nurses (FCNs) may encounter LGBT persons in the faith community in need of care and referral for health concerns. Faith community nursing “focuses on the intentional care of the spirit as well as on the promotion of wholistic health and prevention or minimization of illness within the context of a faith community” (ANA & Health Ministries Association [HMA], 2012, p. 55). This article will help faith community and other nurses to define LGBT, be aware of reasons LGBT persons are at risk for healthcare disparities, refer LGBT persons to appropriate healthcare resources, and discover ways to be more welcoming of LGBT persons.

UNDERSTANDING LGBT

LGBT stands for Lesbian, Gay, Bisexual, and Transgender. Sometimes LGBT is used as an umbrella term for those who generally do not conform to mainstream sexual orientation and gender norms. This abbreviation is also rendered GLBT, and other variations include LGBTQQI (Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning, intersex), or LGBTQQPA(H), (Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Pansexual, Asexual, [Heterosexual]) (R. F. Plante, as cited in Paris, 2011, p. 72).

Lesbian is a common and acceptable term for women whose sexual and romantic attractions or behaviors are mostly oriented toward women. The U.S. Institute of Medicine (IOM, 2011) has defined gay as, “An attraction and/or behavior focused exclusively or mainly on members of the same sex or gender identity” (p. 318). Gay is a common and acceptable term for men whose sexual and romantic attractions or behaviors are mostly oriented toward men. It is not acceptable to use the term “gay” derogatorily as a synonym for “bad” or “weird.” Bisexual describes a person who is sexually or romantically attracted to both men and women (IOM, 2011).

Transgender is a broad term used to refer to a diverse group of individuals whose sense of gender identity does not conform to their biological sex. Such individuals “cross or transcend culturally defined categories of gender” (IOM, 2011, p. 319). Transgenderists live in their cross gender role and may take hormonal therapy, but have not had surgical procedures to modify their original male or female sex. Transsexuals seek gender reassignment surgery or hormone therapy to align their biological sex with their sense of gender identity. Others may identify as gender queer or two-spirit, a Native American term that denotes someone who identifies with both the female and male gender or rejects the traditional binary classification of gender. In the past, queer was a derogatory word for gays and lesbians. However, many young LGBT people now embrace the term queer as a positive self-label because it applies to both men and women and is associated with general gender and sexual nonconformity. When working with older adults who identify as LGBT, keep in mind that the term “queer” may still be offensive (IOM, 2011).

Although LGBT persons share the commonality of social stigma and historical oppression, lesbians, gays, bisexuals, and transgender persons are distinct from each other and face unique health issues. LGBT persons represent all races, ethnicities, ages, religions, socioeconomic backgrounds, and geographic locations (IOM, 2011). Because of this diversity, it is important not to assume someone is heterosexual solely based on appearance, or where the person lives, works, or worships. LGBT persons live in 99.3% of the counties in the United States (McManus, 2008). Research by David Kinnaman and Gabe Lyons (2007) published in UnChristian: What a New Generation Really Thinks About Christianity and Why it Matters, found that most gays and lesbians “align themselves with Christianity” (p. 98) and attend a wide spectrum of churches and denominations. In fact, one-third of the gay and lesbian population attends church regularly.

HEALTH DISPARITIES

According to the IOM (2011), LGBT persons are at risk for healthcare disparities. Reasons for this include that LGBT persons seek health and preventative care less often than heterosexuals due to fear of discrimination, they can be subjects of violence, and they fear breach of confidentiality with healthcare providers (HCPs). What do we know about these issues?

Violence. Sexual minorities, like other minorities, are disproportionately subject to violence. The U.S. Federal Bureau of Investigation (FBI) reports 17,500 hate crime incidents were based on sexual orientation between 1991 and 2009. However, this number is a low estimate due to inaccuracies and lack of reporting. The National Crime Victimization Survey suggests a much higher rate—37,800 hate crime incidents based on sexual orientation between 2000 and 2003 alone (IOM, 2011, p. 43). The Gay, Lesbian, and Straight Education Network (GLSEN) found in a 2009 survey that 84.6% of public school LGBT students reported verbal harassment, 40.1% physical harassment, and 18.8% physical assault because of their sexual orientation (GLSEN, 2010). In another study, students at schools with antiharassment policies, gay–straight alliance clubs, and teachers who intervene to stop harassment reported feeling safer (O'Shaughnessy, Russell, Heck, Calhoun, & Laub, 2004). When assessing the physical, spiritual, and emotional health of an LGBT person, it is important to ask about a history of or experience with violence. For example, if a man has experienced intimidation or violence from males in the past, referring him to a male healthcare professional may be a concern. If the person is a youth, be especially vigilant in assessing if she or he feels safe in the church, in school, and at home.

Fear Of Discrimination. Many LGBT persons face sexual stigma. According to the IOM, sexual stigma refers to “the stigma attached to any non-heterosexual behavior, identity, relationship, or community” (2011, p. 61). Stigma can lead to discrimination in health-related care such as refusal of treatment, verbal abuse, disrespectful behavior toward the client or significant others, and failure to adequately assess and treat LGBT specific health issues (IOM, 2011).

Even in the absence of discrimination, the long history of stigma can create a fear of discrimination that may cause LGBT persons to forgo preventative care, delay care, or to hide sexual orientation or behavior from their HCP. Mays and Cochran reported in 2001 that 58% of lesbians and 51% of gay men “perceived experiencing discrimination” as opposed to only 36% of heterosexual women and 34% of heterosexual men (as cited in Eliason, Dibble, DeJoseph, & Chinn, n.d., Chapter 3, p. 7). A 2010 study found that approximately 30% of LGBT adults delayed or did not seek care compared with only 17% of heterosexual adults (Movement Advancement Project and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders, 2010). Researchers have found that LGBT people of color may be even less likely than white LGBT persons to disclose their sexuality to healthcare professionals (Eliason et al.). The American Medical Association (AMA) encourages physician offices to post public statements such as, “This office appreciates the diversity of human beings and does not discriminate based on race, age, religion, ability, marital status, sexual orientation, sex, or gender identity” (AMA, 2007, para. D-65.996). FCNs also can use various methods to encourage all persons in the faith community to seek help when needed.

From the provider perspective, the IOM notes that in a 1986 study, 40% of physicians reported being uncomfortable providing care to gay and lesbian patients. However, in a 2007 follow-up study, Matthew and colleagues found that provider prejudice in sexual orientation is declining (as cited in IOM, 2011). There are now many providers who welcome LGBT patients. Nurses can help LGBT persons find a welcoming, culturally competent provider on The Gay and Lesbian Medical Association (GLMA) website (see Web Resources).

Discuss Confidentiality. Many people, regardless of sexual orientation or gender identity, hesitate to share sexual health information with a healthcare professional. Furthermore, healthcare professionals generally don't ask about sexual preferences (Eliason et al., n.d.). As an FCN, discussing and ensuring confidentiality with all clients, including LGBT persons, is paramount to assisting parishioners with their health needs (McManus, 2008). Confidentiality should be discussed early and reassured regularly with all clients, and is especially crucial when assisting LGBT persons.

SPECIFIC HEALTH CONCERNS

Many think of HIV/AIDS among LGBT as a major health concern. HIV/AIDS remains a growing concern for men who have sex with men (IOM, 2011), but also is a concern among heterosexuals with multiple partners and among illicit drug users. FCNs can play an important role in encouraging and promoting biblical sexual practices (abstinence before and fidelity within marriage), and when needed, safe sexual practices—for all people in the church. However, we need to think much broader than sexual practices and/or HIV/AIDS in caring for LGBT persons.

For the most part an LGBT person will suffer the same health problems as a non-LGBT person, but she or he may not be as likely to seek care. LGBT persons also face specific health problems. For example, LGBT individuals have been found to use tobacco, alcohol, and other substances at a higher rate than their straight counterparts (GLMA, 2012). As with heterosexual individuals, sexually transmitted diseases occur at higher rates in LGBT persons who are sexually active with multiple partners. Table 1 lists health concerns for which LGBT persons are at higher risk.

Nurses can educate LGBT persons about issues to discuss with their HCP. Gay men should have conversations with their provider about safe sexual practices, hepatitis A and B vaccinations, human papillomavirus (HPV) and other STD screening, substance abuse, and prostate, testicular, and colon cancers (GLMA, 2012). Lesbians should talk with their providers about breast cancer, heart health, tobacco use, and domestic violence. Lesbians should be encouraged to receive regular Papanicolaou (PAP) screenings at the same intervals as heterosexual women (Roberts, 2006). Transgender persons should talk about surgical history, hormone use (prescribed and unprescribed), history of violence or abuse, and any use of injectable silicone. Advise transgender women not to use injectable silicone from “pumping parties” as it can be low quality, contaminated, or injected through a shared needle. Providers need to know which organs a transgender client still has. For example, a transgender male may need PAP screenings if he has chosen not to have bottom surgery and still has a uterus (GLMA, 2006, 2012).

It is important that LGBT persons talk with their HCP about their sexual orientation. Free handouts of the “Top 10 Things” to discuss with HCPs can be obtained from the GLMA website (GLMA, 2012). Although many of the topics presented (depression, smoking, alcohol, and substance abuse) are issues an FCN should encourage everyone to talk about with their provider, LGBT persons continue to face health disparities in these areas. FCNs can improve care by encouraging LGBT persons to talk about their sexual orientation, sexual behaviors, and gender identity with their HCP. If their provider is not aware of their LGBT status, important diagnoses may be missed.

MENTAL HEALTH

In 1973, the American Psychiatric Association (APA) declassified homosexual orientation as an emotional disorder. With this declassification, the APA recognized that homosexuality, “in and of itself, was not associated with emotional and social problems,” such as higher suicide rates, depression, and alcohol use, but may be related to “external stressors and lack of emotional support” (Tate & Longo, 2004, p. 28).

The majority of LGB persons do not report mental health concerns, and while studies of Transgender adults are less available, most report being mentally healthy (IOM, 2011, pp. 189–190). However, compared to heterosexuals, LGBT adults experience chronic stress (GLMA, 2012), are 1.5 times more likely to suffer from anxiety and depression, and more than twice as likely to attempt suicide (IOM, 2011). Remember too that LGBT persons are more likely to experience bullying and physical violence, which increases stress and contributes to ill health.

Unfortunately, LGBT youth have a high risk for depression and suicidal ideation. Risk factors include feeling isolated, substance use, early sexual initiation, not feeling safe at school, cigarette smoking, inadequate social support, homophobic victimization, and stress. Family and parental rejection when a youth comes out as LGBT may increase the risk of suicide (IOM, 2011). Two studies (D'Augelli et al., 2005; Ryan, Huebner, Diaz, & Sanchez, 2009) point to higher rates among LGBT teens of suicide attempts, depression, and high-risk behaviors with family rejection. Another study by Ryan, Russell, Huebner, Diaz, and Sanchez (2010) suggests that support and acceptance from families can decrease the risk of depression and attempted suicide. TheTrevorProject.org is a helpful resource for crisis and suicide prevention for LGBT youth.

If you identify as heterosexual, it may be hard to put yourself in the shoes of a gay or questioning youth or adult in your church. Imagine if the situation were reversed and when you declared your attraction for someone, you were rejected by your family and members of your faith community. Imagine being a teenager wondering if life is worth living without God, your friends, or your family. If an LGBT person expresses suicidal ideation, you do not need to say you understand him or her or what s/he is going through. But you can say you empathize with what a profound sense of loss it must be to feel rejected by those you love. Then tell the good news: God has not rejected her, despite what she may have heard from others, and that he loves her very, very much. Explain that you must communicate your concerns for his or her safety, but not her sexual orientation or gender identity, to others because you care deeply for him/her, and make plans with the person for safety. Familiarize yourself with how to assess suicide risk and appropriately intervene (Captain, 2008).

CARING SUPPORT

There are many ways that any nurse and FCN can be welcoming to LGBT persons. First and foremost, demonstrate the love God has for all people. Reach out to all, especially those who struggle to “fit in” or feel a part of the community of God. Invite LGBT persons to participate in the community. Speak out against discrimination and anti-LGBT name-calling. Help those who struggle with accepting LGBT persons to understand the myriad and complex issues involved in sexual identity and orientation. Your denomination may have position statements about LGBT that can be helpful to you and others.

It's important not to assume all people in the church you care for are heterosexual. As you are open and welcoming, you create an environment where LGBT persons feel safe enough to share their lives and needs with you. When an LGBT individual comes out to you, do not attempt to change or convert him or her to heterosexuality. Andrew Marin (2009), a Christian straight man who immersed himself in the LGBT culture and started the Marin Foundation to build bridges between Christians and gays, suggests that first and foremost we are called to love and build relationships with all people, including gays. Marin bases this call to love (i.e., not condemn or persuade or change but love) on Christ's words (John 15:9–13). As you care for LGBT persons, be aware of your own attitudes, beliefs, and stereotypes, and how they may affect your clinical judgments. Ask God to help you love as he loves. When a person comes out as LGBT keep personal religious beliefs to yourself for now; if you work to develop a loving relationship with this person, there will be plenty of time to share beliefs together. If you have condemned or shamed an LGBT person in the past, consider going back to that person, apologizing, and attempting to reestablish a caring relationship.

The Bible tells us over and over how much God loves all of us. Even though people may reject us, God will never abandon us (Isaiah 49:15–16). Tell youth in your faith community they are God's special handiwork, created in Jesus to do good works, and, because he loves us, he calls us to show his love to others (Ephesians 2:10; John 3:16, 13:34–35). Tell LGBT persons that Christians believe every person is welcome in his kingdom and of worth to God (Matthew 10:29–31).

As with all people in the faith community, assess LGBT persons for family and social support systems. An LGBT individual may have been rejected by family and need a nurse or FCN to act as a health advocate in the hospital or at an appointment. One transgender woman told me how appreciative she was that I came with her the morning of her surgery. Since she had experienced violence from males in the past because of her transgender identity, she was scared she might be put in a male room or treated differently by hospital staff. When talking with her, I accidentally called her by her former male name. I apologized and she said she was glad I cared enough about her to come and advocate for her. As a welcoming FCN, you can advocate for partners, friends, and “chosen family” of LGBT persons who are in the hospital. Help LGBT persons find and complete healthcare Durable Power of Attorney and other legal forms.

A COMMUNITY OF CARE

To create a community of caring in your church, consider participating in welcoming, safe, judgment-free health outreach in the LGBT community. The Marin Foundation has ideas for building bridges between faith and LGBT communities. In my experience, an LGBT member of my church asked the congregation to march in a parade with her to help show other LGBT people God loves them. I know of a church that holds free healthcare clinics and invites the LGBT community. October is LGBT History Month. October 12 is the anniversary of the torture and murder of Matthew Shepard, a young gay man in Colorado. Many institutions use this as a day to talk to youth about the necessity of respect, empathy, and love in our relationships with others. Every year in April, the GLSEN hosts National Day of Silence, where students take a vow of silence to protest bullying, anti-LGBT name-calling, and discrimination. As an FCN, you can help advocate for antiharassment policies in local schools.

For small group study in your church, consider discussing the book UnChristian: What a New Generation Really Thinks About Christianity and Why it Matters by Kinnaman and Lyons (2007), who have researched the way outsiders view Christians. They are optimistic that “outsiders” (their term for people who do not identify as Christian) will begin to see Christians as people who show compassion and love to all people regardless of their lifestyles. The film, “For the Bible Tells Me So” by Daniel Karslake (2007), spurs reflection and discussion about how Christians respond to LGBT people, and could be used for small group study. The film also is a good resource for parents and family of LGBT youth.

If you would like to learn more about the experience of what it is like to be LGBT and how to create safe spaces, explore “ally” training. An ally is someone who works to recognize their biases, learns to advocate for LGBT persons, and speaks out against discrimination. Also called “Safe Zone” training, ally training is offered at many colleges and universities. A web search can help you find the ally training nearest you.

BUILDING COMPASSION

If you are struggling to reconcile your personal beliefs with your practice as a nurse or FCN, it may help you to think about how you have ministered health and healing to others in your church. If an obese person talked to you about overeating, did you tell her it was gluttony or did you listen with compassion and talk about diabetes, heart disease, and weight loss resources? What about smokers or drug users in your church? If a man came to you suspecting he had a sexually transmitted illness did you condemn him? Or did you lovingly refer the man for care, both physical and spiritual?

It also can be helpful to reframe your thinking about LGBT persons. We do not identify heterosexual people by their sexual preference saying “he's straight” like we do LGBT persons. Rather, we identify people in ways such as “he's a business man” or “she's a nurse” (career identification), or “she's an American,” “he's a Republication” (social identification), or “she's a Christian” (religious identification). When an LGBT person comes to you, think about her other life identifications, not just her sexual orientation (Paris, 2011). Listen for how an LGBT person describes himself and then refer to him as he refers to himself.

Researching what is fact and what is myth about LGBT can help build compassion. For example, people may think LGBT persons have uncontrolled or aberrant sexual drives and practices. However, researchers have found that the range of sexual drive and practice is similar for heterosexual and homosexual persons (Eliason et al., n.d.); both can have multiple sex partners or engage in unplanned and unprotected sex. Another interesting fact: The Marin Foundation (Marin, 2009) found that the LGBT community as a whole exhibits very high religiosity, seeking wholeness as all people do.

Finally, and most importantly, practice Jesus' law of radical relationship (Mark 12:31). Become friends with someone who identifies as LGBT. It is never easy to love your neighbor as yourself, especially if some of your beliefs differ significantly. Jesus first and foremost loved people, even people we might shun (John 4:4–42). He loved us before we loved him (1 John 4:19). We may make mistakes as we relate to those who are LGBT, but we are called to care for all people. We chose nursing because we are grateful for God's infinite grace and want to care for the people he created and loves.

My own journey in developing compassion for the LGBT community started with the small step of deciding to accept an LGBT friend and get to know her better. Now, years later, God has turned that decision into a significant ministry. You may face discrimination and stigma because of your compassion for LGBT persons. Do not fear; this will serve to expand and nurture your empathy and compassion. Ask yourself, “How would Jesus treat this person whom others have rejected?”